SL.NO.........

Affix a
recent
APPLICATION FORM passport
For LAMPHANDLING Size
Narayani Institute of Engineering & Technology, Arahat, Angul Photograph
DEPT.OF MINING ENGG.

APPLIED FOR APPLICATION…………………..................................................Date of Applied…………….....

BRANCH……………SEM………YEAR…………..............Mob No

APPLICANT DETAILS
Applicant Name:……………………………………………………………………………………………………………………….

Father’s Name :………………………………………………………………………………………………………………………..

Mother’s Name:………………………………………………………………………………………………………………………..

Blood Group:………………….. Date of Birth: …………(dd)/………………………..(Month)/……………………(yyyy)

Aadhaar No: ……………. ……………..

ADDRESS OF CORRESPONDENCE

State:………………………….. District:………………………………………. Block:…………………………………………….

Address…………………………………………………………………………………………………………………………………..

……………………………………………………………………………………………………..PIN:…………………………………

Telephone(Home):………………………………..Mob No(Guardian)………………………………………………

Email:………………………………………………………..Mob No(Std):…………………………………….

Signature of Candidate

I do hereby verify the choice filling and the personal details stated by me are true to the best of my knowledge. The
above-mentioned choice filling is absolutely based on my option without any pressure / influenced by other person /
authority of Narayani Institute of Engineering & Technology.

Signature of Verifying Officer